Financial Incentives in Health Care

Variation in medical treatment is a necessary part of care because no two patients are exactly alike. This is especially so in cancer, where treatment has become increasingly personalized. Insurers need to allow for this as unexpected deviations from the “norm” may result in equally good — if not better — patient outcomes. Guidelines and treatment pathways are not designed to eliminate all variation, but to eliminate unwarranted variation that can waste valuable resources and may not benefit patients.

At the American Society of Clinical Oncology, we are developing CancerLinQ, a big data initiative to learn from real-world patient care — including both warranted and unwarranted variations — and drive improved outcomes and experiences for patients, while recognizing each patient’s individuality and humanity. We are also piloting new physician payment models, developed by practicing oncologists, that incentivize high-quality care, while preserving the central importance of physicians’ professional judgment and experience.

These efforts allow doctors to do what they are trained and committed to do: improve and save the lives of their patients.

Health plans have long recognized that advancing a patient-centered health system requires a fundamental transformation in how we pay for and deliver care. Across the country, health plans are collaborating with physicians and hospitals to sustain meaningful changes in practice that support patient-centered medical homes and bundled payments. These innovative models are based on evidence-based guidelines, developed by leading medical and specialty societies, that ensure that patients receive the right care at the right time.

A coordinated approach to treatment and practice allows for patients to be cared for holistically, rather than body part by body part. And the results speak volumes — patients experience improved health outcomes from care that is truly patient-centered.

Implicit in Dr. Pamela Hartzband and Dr. Jerome Groopman’s argument is the idea that American health care is moving away from an uncorrupted golden age in which physicians always put patient interests before their own. Unfortunately, such a golden age exists only in myth. The practice of medicine has always been riven by financial conflicts of interest, making it impossible for most patients to know in whose interests recommended treatments lie.

For instance, American surgeons stand to earn up to 10 times as much from surgical treatments as they do from nonoperative management of disease. Unsurprisingly, studies have shown that up to one in three surgeries performed in this country are inappropriate or unnecessary. The financially conflicted decision making that leads to this dangerous overuse is generally invisible to patients and is best addressed in our fee-for-service system through quality metrics.

Such quality measures are an attempt to counter the sometimes skewed financial incentives inherent in medical practice. If doctors object to outside agencies thrusting such metrics upon us, we must do a better job of confronting our own existing financial conflicts of interest.

JAMES RICKERT Bloomington, Ind., Nov. 19, 2014

The writer, an orthopedist, is president of the Society for Patient Centered Orthopedics.

To the Editor:

Dr. Pamela Hartzband and Dr. Jerome Groopman have a point in claiming that statistically correct treatment standards may be wrong for a minority of patients and that some knowledgeable physicians may choose to vary their care away from advised standards in a way that may benefit a particular patient.

Too many physicians, however, stray from accepted norms because of incomplete knowledge of state-of-the-art standards, not because, after careful consideration of all possibilities, they are smart enough to know that trying a different course may benefit a particular patient.

No “health policy expert” has ever suggested to me that “it is obsolete to approach each patient as an individual.” But the norms of care work better for the majority of patients than some of the disturbing variations to which some patients are exposed.

Perhaps financial rewards in the form of pay for performance are not the best way to encourage optimal physician behavior, but it seems reasonable to look for ways of improving medical care in a country that has the most expensive care in the world but far from the best.

LONNIE HANAUER West Orange, N.J., Nov. 19, 2014

The writer is a rheumatologist.

A version of this article appears in print on , on Page A30 of the New York edition with the headline: Financial Incentives in Health Care. Order Reprints | Today’s Paper | Subscribe